In general surgical practice, post-operative infections contribute significantly to surgical morbidity and mortality. A national survey in 1984 by the Centers for Disease Control in the United States, reported surgical wound infections in 0,47% of all hospital discharges [8]. In a survey of 62,939 surgical operations, Cruse found an overall rate of wound infection of 4,7%, but also found that the rate markedly increased when pus or a perforated viscus was found at operation [12]. In this study, the infection rate for « clean » surgery (where no infection was encountered, no hollow muscular organ was opened, and no break in aseptic technique occurred) was 1,5%, while the rate was 7,7% after clean-contaminated procedures (those in which a hollow muscular organ was opened but minimal spillage occurred). After contaminated procedures (those with acute inflammation without pus, gross spillage from a hollow viscus, a major break in aseptic technique during the operation, or acute trauma of less than four hours), a 15,2% infection rate was noted, and a 40% infection rate was found when pus was encountered at operation or where traumatic wounds had existed for more than four hours, that is, so-called dirty cases.
Use of Prophylactic antibiotics
On the 10th and 11th of December 1992, the French Society of Anesthesia-Reanimation held a consensus conference on the use of
prophylactic antibiotics in surgery. The jury came up with specific rules and recommendations for each type of surgery.
For all types of surgery some patients are at risk of post-operative infection. They include:
- patients who are immunosuppressed, who have undergone radiotherapy or are undergoing corticotherapy or chemotherapy, diabetics, very old (>85 years), obese (presumably because adipose tissue is poorly vascularised) or very thin.
- patients with a valvulopathy or a prothesis.
- patients who have undergone organ transplantation.
Prescription of Prophylactic Antibiotics
Prophylactic antibiotics (PAB) are recommended to be administered intravenously with a delay of one and a half to two hours before the operation, if possible during anesthesia with a short duration of 24 hours usually (48 hours exceptionally).
The antibiotic is targeted to act on definite bacteria which usually cause a particular infection and not on all bacteria present in that particular area.
Protocol for PAB in Digestive Surgery
Surgical operations involving the gastrointestinal tract (GIT) correspond to either a « clean » surgery in the absence of opening of the GIT, or more often to a « clean-contaminated » surgery if the GIT is opened.
Hemorrhoidectomy is considered a « clean-contaminated » surgery. A standard protocole proposed for digestive surgery is an antibiotic injection before and perhaps during the operation depending on the pharmacokinetic of the drug and the duration of the operation is shown in Table 2 (recommendation shown here are limited to the scope of this study) [9].
Table 2
Recommendation for prophylactic antibiotics in digestive surgery
Surgical operation Drug Dose Duration
Proctological surgery Imidazole 0.5g preop single dose Metronidazole
Ornidazole
A retrospective study was done on the records of one hundred and twenty-five (125) consecutive hospitalized patients who underwent hemorrhoidectomy by the Milligan-Morgan method, at the Visceral Surgery clinic of the University hospital of Geneva (Hôpital Cantonal Universitaire de Genève). They were hospitalized during June 1995 and September 1997.
From the nurses observation chart, axillary temperatures of the patients on the day of the operation (D0), and the first three days after the operation (D1, D 2, D3) were noted. Their sex, age, duration of hospital stay, past medical history, treatment before and after hemorrhoidectomy were studied and noted. The patients are followed up once a week after discharge from the hospital for about six weeks. Their hospital as well as ambulatory medical files were examined for any post-operative complications. For all patients who had temperatures greater than 37,2°C, their white blood cell count, C-reactive protein (CRP), sedimentation rate, blood and urinary cultures if available were carefully studied. These complementary exams were not routinely done for all the patients.
VI RESULTS
Out of the records of one hundred and twenty-five patients examined, only one hundred and fourteen (114) were finally used for this study.
The records of eleven (11) patients were eliminated because either there was no temperature recordings or because their temperature was recorded only once during their hospital stay. Out of these 114 patients, fourty-eight (42%) were females, and sixty-six (58%) males, with an age range between 17 and 84 years. These patients underwent regional perineal anesthesia prior to hemorrhoidectomy. The mean hospital stay was 3 days, with a minimum of 2 days and a maximum of 9 days.
Based on Wunderlich’s original observations over 120 years ago, the overall mean temperature for normal individuals aged 18 to 40 years is actually 36,8 +/- 0,4 °C (98,2 +/- 0,7°F). The maximum normal oral temperature at 6 a.m. is 37,2°C (98,9°F) and the maximum normal temperature at 4 p.m. is 37,7°C (99,9°F) both defining the 99th percentile for normal individuals [23,40].
In the Digestive surgery department, axillary temperatures were taken in the morning for all the patients. Using the above criteria, a temperature greater than 37,2°C (98,9°F) would define a fever. In the study, out of 114 patients, seven (6%) had a temperature between 37,3 and 38,0°C on the day of the operation (D0), that is before the operation; two of them maintained their high temperatures during their hospital stay; for the remaining five patients, their temperatures returned to normal after the operation. On the first postoperative day (D1), seven patients (6%) had
temperatures between 37,3 and 38,0°C, one had 38,6°C (Table 3, graph ).
On the second postoperative day (D2), except for three patients, they all had their temperatures returned to the norm. These three patients eventually had a normal temperature on the third postoperative day (D3).
No patient developed or had fever on D3. (Table 3)
None of the patients with fever had any post-operative complications.
Complementary examinations done for the one with temperature of 38,6°C on D2 and D3, showed negative blood and urinary cultures, with CRP of 42,8, and no leucocytosis (white blood cell count of 8,2 G/L (normal range 4,0 to 11,0 G/L).
Table 3 and Graph
The relationship between percentage of patients with a rise in temperature and day(s) after hemorrhoidectomy in this study.
PERCENTAGE OF PATIENTS WITH TEMPERATURE
DAY <37,3°C 37,3>38,0°C >38,0°C
Graph (Graphique ) :
The relationship between percentage of patients with a specific temperature after the operation.
0%
The general treatment after hemorrhoidectomy is Metamucil, analgesic (such as Tramal, Voltarene, or morphine) and sitz baths. However, two patients were treated with antibiotics after the operation on D0 without a specified reason. One patient was treated for scabies with antibiotics (Augmentin and Flagyl) during his 8-day hospital stay. There were three patients with total hip replacement, one with ear prothesis and another with urethral prosthesis who did not have any antibiotic prophylaxis.
However, none of them had any post-operative complications and not even fever, and hence no bacteremia.
During the six weeks postoperative follow up, no septic complication was noted in the patients’ medical files.